What doctors need to know about domestic violence and abuse

One area of research focusing on domestic violence and health is linked to training and the medical education curriculum. A number of barriers have been identified which might prevent doctors and other health professionals from addressing the issue of domestic violence and abuse. A key barrier was a lack of training, and in the UK, the IRIS (Identification and Referral to Improve Safety) training package has been developed, and proved to be effective. General practice staff are trained to identify, document, and refer patients who might be experiencing domestic violence and abuse to a local specialist agency. Doctors report feeling more prepared and better able to deal with domestic violence.

The women we interviewed said they want health professionals to learn more about domestic abuse so they can recognise the signs, and understand that it takes time for women to feel safe and able to leave. They said they want doctors, nurses and health visitors not to be afraid to ask women how things are at home, since women experiencing abuse will rarely take the initiative to talk and may not recognise that they are experiencing abuse. They felt that doctors must not collude with ‘normalising’ abusive behaviour, and they could hand out contact cards for Domestic Violence and Abuse Agencies, ‘just in case’.

Linda is a 59 year old white British woman, separated from her British Caribbean husband. Her two daughters from a previous marriage and her four grandchildren live locally. Linda used to work as a University lecturer and as a manager of children’s services, but is now unable to work owing to severe health problems, Reactive Airways Dysfunction Syndrome and Osteochrondrosis.

And then on the Monday I had my physio appointment and the physio said to me, oh my gosh this is terrible you know your hips, what have you done, because I could hardly move them, my shoulder I couldn’t ‘cos of the, I told a lie I said I’d been knocked over by a little boy on a bike.

Okay. She accepted that?

It was a man [tearful]. He said, “This is, I can’t believe from a week ago, that it’s so bad, you know, so different the movements to how you were”. And he said “These bruises”. I said “I know I was coming down that slope at the hospital because there’s a big slope there and I said this little boy on his bike, on his scooter it was, on his scooter” and he said “oh dear me”.

So what happened next?

Nothing, and then I went back for my next week’s [medicine] injection and I was going to tell my consultant because I really trust her and she was in a real rush and she was really busy.

Just when you decided.

Yeah I decided, and she had this lovely patient with her, I can’t remember his name, and he’s having them as well and he didn’t feel well and his wife wasn’t very well and his wife had just found out she’d got cancer so I couldn’t tell her because she was really upset because his wife, so my problems weren’t as bad as his wife’s, and yeah so I didn’t’ tell her.

When I went to the health service I was having a coil fitted and they couldn’t fit it so I had to have a general anaesthetic to have it fitted at the hospital and it was the time I was telling you about where I was covered in bruises and a week later I had to go and have this coil fitted and when I came round and there were auxiliary nurses they were called then and she came to me and she said you’ve got terrible bruises all over your back and your shoulders and your bottom and she said how did that happen and I went, I said “Oh um I think I just, oh I fell out of bed”. She said “oh okay” and that was all she said and they were so bad and what I wanted her to say was we’ll write this down in your notes, that’s what I wanted her to say was we’ll write those down in your notes that’s what I wanted her to say and then I was hoping it would be in my notes so that somebody else would ask me. Because the reason why I didn’t say anything because you know when you come out and it’s only, you’re only in for the day?

Yeah.

You only have those curtains, there’s so many people, you’re not in a ward, you’re not in a room and I was frightened because he was going to come and get me.

And you didn’t want anyone.

No I didn’t want him coming while I was saying it.

Yes, yes of course. I think that’s a really important point that you’ve just made actually, about what it’s like and about how it was with the health professionals and the nurse and that about actually recording things in the notes, that would have been better for you if somebody.

Perhaps if somebody has got those bruises or something you’re concerned about and you want to ask that question, perhaps when, make sure you have put them in, if you’ve got it a room where it isn’t just those curtains so you can ask them, because I would have said, if I wouldn’t have been in just on a bed with a curtain he, you know because the door was there and I was looking because the bottom curtain was open so it was only the two side ones from the other two people, women on the beds and that door so I would have been able, yes, I would have been able to see him come but.

So at that moment in time things could have changed for you.

It could have changed with the police officer that time and a week later if that nurse, if I wouldn’t have been in that situation where he could have come in at any time.

Helping women to recognise domestic abuse could be done by, for example, having a domestic violence and abuse specialist or a survivor available at a practice, or by running nurse-led discussion groups.

Anna is a single, white British woman. She lives in a council property with two of her six children, one of whom has special needs. She works part-time as a volunteer for two charitable organisations.

About domestic abuse and violence, so again, based on your experiences, what do you think are the most important things that they need to know, that they need to be made aware of?

That women going through it aren’t aware it’s abuse. I didn’t know. It’s with being educated with the Freedom Project and stuff, because that’s not the way I grew up and I didn’t grow up seeing that. So, yeah, I didn’t know it was abuse. And especially the sexual side, if you’re in a relationship with, then you feel that they have a right. So somebody needs to educate the women and sort of explain that, what’s happening as well.

How, how can …

Not saying that they are wrong.

Yeah.

Not pass the blame to them.

How do you think that can be done then? That education. Putting you on the spot aren’t I? [Laughs]

Yeah.

[Laughs]

There is, there is the Freedom Project, but maybe just have group meetings in doctors’ surgeries where, you know, women who are just going through a bad time, they don’t have to know it’s domestic abuse or something but maybe, you know, if you’ve got group of some patients maybe just to, group meetings where they can, they can be told they can come and talk about their problems, but actually it’s …

So peer, peer group …

Yeah.

… facilitated by a GP or health professional, do you think? Or…

Health visitor, maybe. Even, but then health visitors only attend families with, with not school aged so maybe like a, like the nurse or something. Someone a bit more trusting that they’re not going to take the children away.

Women said they want GPs to get to know their patients and probe beneath ‘what is presented’. They stressed that listening is more important than giving advice, although giving contact details for domestic violence and abuse organisations is helpful. Shaina suggested that health professionals should be able to put women in touch with other survivors of domestic abuse, who could offer support and understanding.

Women also said they wanted reassurances about confidentiality and opportunities to talk to the doctor on their own, since controlling partners often insist on accompanying women to their appointments. They also want doctors to recognise a women who is suffering from trauma rather than a mental illness.

Victoria is a white British woman who lives in a privately rented home with her son, aged three. She works part-time as a support worker and at the time of interview had recently started a new relationship.

What do you think health professionals need to know?

Firstly make sure that they have appointments, just them and the person that they think is being abused. Because if the partner goes along they’re not going to say anything, because they’re going to be abused even more when they get home. And it needs to be linked up. Like there seems – it seems short-circuited, like these professionals contact those but they don’t contact the other ones. And so it kind of needs to be in a loop. But [local] Council seriously need to look at their – the way that they house people. You can’t just say to people, “Oh well unless you’re being murdered then, no, you’re going to have to stay in your situation.” that was the most shocking.

And when they said that on the phone, how did you, how did you feel?

They might not have worded it like that.

But that kind of thing, yeah.

That’s right, they have to cover their tracks. And I know that they’re all recorded, the calls. But it was to that effect like, you know, unless – “Are you in an emergency situation?” “Well I’m not being murdered right now, but I am in a domestic abusive relationship and I really need to get out right now.” And that wasn’t heard, yeah.

And when it wasn’t heard, how did you feel?

Totally isolated. Angry at myself that I wasn’t financially independent to just go.

Doctors need to pick up signs and ask questions

Mandy said doctors should notice if a woman is ‘knackered’, ‘not sleeping’, ‘crying for no reason’, ‘very anxious and twitchy’, or if they or their children are ‘constantly at the doctor’s with pains or other complaints’. Philippa and Jane suggested doctors could start a conversation about women’s lives that could lead to more specific questions, and they should offer information about services even if the woman does not respond at the time.

Mandy is a white British woman who is educated to degree level. After a period off work with depression, she now works full-time and is currently living with her new partner and dogs.

What do you think are the most important things that kind of health professionals need to know about domestic abuse and what it’s like to be in an abusive relationship?

That very often, unless it’s actually physical, that that person might not even know it’s happening to them. As I say it sort of sneaked up on me gradually. It’s not like, one minute you’re all hearts and flowers and the next minute .there’s a fist in your face, and you sort of think, Oh”. It sneaks up on you. It’s like gaining weight, you don’t notice until you go to put on last year’s bikini and you can’t get your leg in it.

[Laughs]

[Laughs] And then you’re just sort of confronted with it. So it’s looking out for those little signs, you know, is somebody not sleeping, is somebody, you know, crying for no reason, are people feeling hopeless? It’s, it’s the little things like that. I thought it was down to my work situation, in fact I hated my job. I was screwing up and getting into trouble, and now I know it was the situation with him that was causing that. It wasn’t the fact that I was crap or useless. It was what I was having to deal with, without knowing it.

Yeah. Yeah.

Yeah.

So it’s kind of, being able to recognise that in people who come, women who come into their...

Yeah.

… their surgery. Anything else that you feel that they need to know, or be aware of?

No, I think that’s about it. I mean it, it might not be, if there’s children involved it might be affecting the kids as well, maybe it’s one of the kids that comes in and, and says that, you know, they’re having nightmares or, yeah, it might not be the parent. And it might not just be women, it can equally apply to men.

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Jane is a single, white British, unemployed woman. She is a mother of two and lives with her youngest daughter in a privately rented home.

And one of the aims of this project is that we’re hoping to educate doctors and nurses about domestic abuse. So based on your own experiences then, what do you think are the most important things that they need to know?

What, health professionals?

Yeah.

The right questions to ask.

And what do you think those right questions could be?

“How are things at home?” You know, to start off with. If they have a suspicion that domestic abuse is occurring then to have the time just in that appointment to be able to say, “Look, there are services available,” even if you have to show it on the computer because you can’t take leaflets away with you, “there’s this service, there’s that service, there’s something other service.” And don’t be afraid for the, to broach the subject. You know, because it’s quite a taboo subject, or you think you might have crossed the line because you’ve gone into sort of like the, the patient confidentiality thing, but don’t worry about that. You know, ask those questions and just reiterate the fact that, you know, there is help available.

Yeah.

And that if you wanted to talk about it then, you know, there’s definitely so much help available.

Doctors need to listen and to reassure women about confidentiality

Many women, like Tina, stressed that doctors need to win their patient’s trust by listening rather than prescribing tablets.

Tina is a 50 year old single white British woman, living with her dog and her son’s tortoise in a Housing Association house. She is unable to work owing to health problems, including COPD and migraines. She has close contact with her daughter and grand-children who live locally, but poor contact with her other five adult children and her younger son who is away at University.

If you had a message to give to the doctors out there, what, what would it be?

Just please listen to what people saying. D’ye know what I mean, just because they walk into the practice and think that, yeah, everything’s fine. No, it’s not. Do you know what I mean?

Sure, yeah.

They ain’t going to get trust in you, patients, ain’t going to trust you until you be nice to them do you know what I mean? And because not being funny because I trusted, I put my, well my daughter’s life into a consultant’s hand and that happened I wouldn’t even open up to anyone, do you know what I mean?

I just wouldn’t open up to anyone, but now the doctor I got she is lovely, she just. She is brilliant. You can tell her anything d’ye know what I mean, she is lovely.

You did have some bad experiences with doctors from what you’re saying?

And it’s no good oh well, yeah this has happened, oh here’s some tablets. That didn’t just cure it la, la.

No.

Keep trying to zombie you.

Women wanted assurances about confidentiality before they felt safe to talk about abuse. They needed to be sure their partner would not find out and also that they would not lose their children. Tasha said that doctors should look out for signs of domestic abuse, and if abuse has been identified, they should be more aware of helping women to stay safe, for example if they are in hospital.

Tasha, a white British woman, lives with her husband and four of her five children (ages 9 months – 21 years) in a privately owned home. She is unemployed, living with condition affecting her joints, and is registered disabled.

To basically to look out for signs for people that are in it. And like I said, just keeping people safe who are, because it seems that they always, they’re always there and they always try to find a way in no matter how. I mean, at the hospital it, it was said that he wasn’t allowed to come in the hospital if I was in there. Well what stops him from giving a false name? You know, they weren’t checking IDs as people come in.

And they were just asking who, who they were and who they’d come to see. So he wouldn’t give his own name if he did, so, you know, just, you know, really sort of looking out for people to keep them safe I think. Thinking beyond, you know, if somebody says, you know, they can’t come in hospital, give names and perhaps a photo of people who can come in.

Yeah.

You know, just …

Yeah.

… to keep people, people safe, because you know, they will find a way if they really want to. I mean, my address was all kept secret but he managed to hack my email account then, because he knew when I first moved up here, obviously he knew my first pet’s name, he knew where I was born, he knew my primary school…

Yeah.

… my mother’s maiden name …

Yeah.

… so he got into that and I had a delivery coming from Tesco’s to this address, because it was a new house what I was moving into, so obviously I needed stuff, so he got my address because it said it would be delivered to this address on such and such, so that’s how he found it. So, you know, if they, they want to, people really need to be vigilant and stuff.

Tread gently

Women want doctors to proceed sensitively if they suspect domestic violence or abuse and to be aware of women’s anxieties about disclosure so they do not feel pressurised into taking action when they are not ready or safe to do so. Health professionals need to understand that women are brainwashed and become emotionally dependent on abusive partners which makes it hard for them to leave. Tanya’s support worker suggested she had Stockholm syndrome* so ‘no matter how horrible your abuser is, you’re in love with them’.

Ana is white European and divorced. She has been living with her new non-abusive partner for one year, with her two children aged eight and ten years, in a rented flat. She works full-time as the Administrator of a Children’s Centre.

What would you like to say to health professionals, if you had the chance?

Yeah, yeah, I actually, I actually work in a children’s centre. We have like health visitors, midwives …

Right.

… come and we have a lot of families and …

Right.

… when I’m not going to kind of say names or nothing.

No, of course, yeah.

And we had a case of a young mum, pregnant mum being in an abusive relationship, and she left and I kind of put her into contact with the notice board with someone.

Is there someone on the staff of where you work or …

This was a mum that come to see a midwife and so I gave her the number and the midwives were talking next week, week after, “Oh she didn’t ring them,” and I just said,“You need to, you need to let her decide for herself.”

Right.

Obviously there’s an issue of, you know, safeguarding and if they need to contact …

Yeah, yeah.

… social services, there is that. But I said, I did say to them, “You, with women, it’s really important not to pressure …”

Right.

It’s, they need to be kept safe and if there’s immediate danger, which I get … is the pressure of if you don’t leave, I think all women have that, which I had that thought, social services will come and take your child away. It’s very scary, just all of a sudden people [pause], you know, jumping on, on, on her case and like, “Oh you have to, you have to ring them or X, Y and Z will happen.” So I think that’s my main … just kind of being considerate of that and just a woman, a woman will kind of hopefully have that, you know, point and just say, do you know what, enough, in herself.

When she’s ready.

When she’s ready, yeah.

Doctors need to recognise trauma

Doctors failed to recognise that some women, such as Min and Alonya, were suffering from trauma, leading to an incorrect diagnosis of a mental health problem and delays in getting proper treatment and support.

Min is a 47 year old mixed race single woman living with her four children in a privately rented home in a rural area. She works as a Pilates teacher, alongside her training to become a lawyer and is engaged in consciousness raising about domestic violence and abuse.

If you had a message to give to doctors or people in healthcare, what would that be?

OK, the message is this. A woman comes to you because she is stressed, because she is anxious, but she doesn’t say anything else: you need to consider that she’s scared of you. You need to consider that she’s scared that you might pick up the phone and telephone Social Services or the police, because there are child protection issues, so she will lie, she’ll minimise, she will deflect. But you need to understand that there could be abuse there that she can’t qualify and quantify, but it is there. And I believe that you have a duty of care to look beyond what is presented to you. You have a duty of care to see that the person who could be over-emotional, anxious, stressed, is not necessarily mentally ill, but could be traumatised, could be severely sleep deprived because they’re being sleep raped three or four times a night. You need to consider things like that. You need to consider that what you see is the tip of the iceberg. You need to be open to that. And you need to ask questions properly. You can’t just go in there and just say ‘have you been abused?’ because people will clam up, especially if they’re scared of their children being removed.

Yes.

Yeah, I’ve got quite a lot to say on that [laughs] subject.

That’s good.

Funnily enough. And you need to be sympathetic. And you need to make proper notes, because it’s no good [sniffs] having someone come to you, a patient say de, de, de, de, whatever, and you write some crappy little note that a year later you are asked to retrieve, that says nothing.

Do a shorthand course, but you need to write proper notes. Because it’s a way of evidencing, it’s a way of gathering information to look for a pattern of behaviour that would otherwise fall beneath the radar. And they need your help. So proper notes are good.

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a 31 year old British woman originally from Eastern Europe. She lives in a Housing Association flat with her nine year old daughter, and works part-time as an office co-ordinator.

If you had a message to give to some trainee doctors and, and wanted to help them to learn about, what, what, what would you like them to know do you think from your own experience?

Probably about some, I don’t know how to explain…

Don’t worry if it’s a difficult question, you don’t…

…it’s a hidden trauma.

Yes. Yes.

So, I was, for example, through [local mental health centre] psychology, they have standard questions…

Right.

..and I was not diagnosed for trauma for long time…

Right.

…and they were saying, well it’s a, you’re going quite normal, as average…

Right.

..but I felt, feel that I wasn’t average.

Yes.

So I wasn’t diagnosed on time for trauma.

Right. When were you diagnosed?

In April this year.

This year?

Yes.

So, you think …

I think they need to have more deeper questions…

Yes. Yes.

….and I think when somebody saying that you had a domestic violence, more, probably less should be different questionnaire…

Yes….

…for those people.

*Stockholm syndrome refers to feeling of trust or affection felt in many cases of kidnapping or hostage-taking by a victim towards a captor.